Association between diabetes and esophageal cancer, independent of obesity, in the United States Veterans Affairs population.

In the past 30 years, the incidence of esophageal adenocarcinoma (EAC) has increased more rapidly than any other cancer in the United States. The prevalence of obesity and diabetes mellitus has drastically increased as well. We explored the potential association between obesity, diabetes mellitus, and EAC. By means of retrospective interrogation of an administrative database from fiscal year 2005-2009, we identified two cohorts. The cancer cohort was defined as patients with adenocarcinoma of the distal esophagus or gastric cardia. The comparison cohort contained patients with gastroesophageal reflux disorder (GERD; diagnosis coupled with a procedure code for fundoplication). Patient data, including demographic measures, diagnoses of obesity, diabetes mellitus, dyslipidemia, alcohol abuse, and nicotine dependence were examined. A logistic regression model identified risk factors for development of EAC. The sample included 2,836 patients identified as having either EAC (1,704) or fundoplication with GERD (1,132). Although slightly higher percentages of the benign cohort were obese, the cancer cohort had more diabetics (30.8% vs. 14.8%; chi-square = 94.5; P < 0.0001). In a logistic regression analysis adjusting for comorbidity and lifestyle factors, diagnosis of diabetes mellitus was significantly associated with esophageal cancer as opposed to GERD without cancer (OR = 2.2; 95% confidence interval [CI] 1.7-2.8). Nicotine dependence was also identified as a risk factor (OR = 1.7; 95% CI 1.4-2.0). We identified a potential association between diabetes mellitus and adenocarcinoma of the esophagus or gastric cardia. This association appears to be independent of obesity. Additionally, nicotine dependence was identified as a risk factor for EAC.

[The effect of small doses of 7.5% NaCl on brain bulk during elective craniotomies]. / Wplyw malych dawek 7.5% NaCl na objetosc mózgu podczas planowych kraniotomii.

In 16 patients (ASA I i II) aged 16-76 years (48 +/- 15; mean +/- SD) operated on because of intracranial expanding mass, the effect of hypertonic saline (7.5%--1 ml/kg b.w.) on brain bulk (BB) was evaluated. Patients were anaesthetised with a slight hypocarbia (PaCO2 = 33.3 +/- 3.5 mmHg). BB was scored after opening the dura (T0) and 15 min. (T15) after hypertonic saline (HS) infusion. Five points BB scale was used. Brain bulk reduction (D BB) was calculated as a difference: BB15-BB0. Tomographic signs of intracranial expansion (TSIE) in preoperative CT were scored using the scale from 5 to 15 points assessing (1 to 3 points) the size of mass lesion, the size of perifocal oedema, midline shift, displacement of ventricles and basal cisterns compression. Systolic (SBP), diastolic (DBP) blood pressures and heart rate (HR) were monitored. Serum natrium (SNa), kalium (SK) and osmolarity (Sosm) were measured at T0, T15 and Tp0 (one hour after operation). Student's t-test, Wilcoxon test and Spearman correlation were used for statistical analysis. P < 0.05 was considered as statistically significant. HS caused significant decrease in BB (p = 0.002). In 12 patients with a solid brain tumor a negative correlation between BB and TSIE was found (r = -0.68). A slight but significant decreases in SBP and DBP at Tp0 and T15 as well as decrease in HR due to HS were stated. SNa and Sosm increased at T15 and reminded elevated at Tpo. We can conclude that 7.5% saline in a dose of 1 ml/kg b.w. reduces brain bulk during craniotomy in patients with supratentorial mass lesions. In patients with a solid brain tumor this effect correlates negatively with a size of expanding mass. A slight changes in blood pressure and heart rate due to HS as well as moderate decrease in SK are within limits of clinical acceptance.

The cost-utility of screening for depression in primary care.

BACKGROUND: Depressive disorders are common in primary care and cause substantial disability, but they often remain undiagnosed. Screening is a frequently proposed strategy for increasing detection of depression. OBJECTIVE: To examine the cost-utility of screening for depression compared with no screening. DESIGN: Nonstationary Markov model. DATA SOURCES: The published literature. TARGET POPULATION: Hypothetical cohort of 40-year-old primary care patients. TIME HORIZON: Lifetime. PERSPECTIVE: Health care payer and societal. INTERVENTIONS: Self-administered questionnaire followed by provider assessment. OUTCOME MEASURES: Costs and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS: Compared with no screening, the cost to society of annual screening for depression in primary care patients is $192 444/QALY. Screening every 5 years and one-time screening cost $50 988/QALY and $32 053/QALY, respectively, compared with no screening. From the payer perspective, the cost of annual screening is $225 467. RESULTS OF SENSITIVITY ANALYSES: Cost-utility ratios are most sensitive to the prevalence of major depression, the costs of screening, rates of treatment initiation, and remission rates with treatment. In Monte Carlo sensitivity analyses, the cost-utility of annual screening is less than $50 000/QALY only 2.2% of the time. In multiway analyses, four model variables must be changed to extreme values for the cost-utility of annual screening to fall below $50 000/QALY, but a change in only one variable increases the cost-utility of one-time screening to more than $50 000/QALY. One-time screening is more robustly cost-effective if screening costs are low and effective treatments are being given. CONCLUSIONS: Annual and periodic screening for depression cost more than $50 000/QALY, but one-time screening is cost-effective. The cost-effectiveness of screening is likely to improve if treatment becomes more effective.